MESDA's 11th Annual Conference
Friday, November 14, 2003 DoubleTree Hotel
Registration
Registration Form
Prepayment is required.Reservations are non-refundable. A registrant may designate
a substitute attendee by calling the MESDA office. Questions? Contact Joe Kumiszcza at
MESDA (207) 829-9195
Organization:
Contact Name:
Title:
Address 1:
Address 2:
City:
State:
Zip:
Telephone:
Fax:
E-mail:
List registrants here (including
yourself, if you will be attending):
Payment Information:
Conference registration Fees: MESDA Members $99.00; Non-Members $129.00
# of MESDA Members Attending: x $99
# of Non-Members Attending: x $129
Total amount enclosed $
Select payment method:
Account Number:
Name on Account:
Billing Address:
Expiration Date:
If you prefer not to submit your credit card information over the Internet
or want to pay by check, please send the completed registration and your payment (make
checks payable to MESDA) to: MESDA, P.O. Box 10020, Portland, ME 04104-0020.
